Outpatient Authorization Request (Medicaid) - WellCare 2025

1. Click ‘Get Form’ to open the Outpatient Authorization Request in our editor.
2. Begin by selecting the type of service you are requesting from the options provided, such as Consultation or Diagnostic Testing.
3. Fill in the required member information, including Member Plan ID, name, phone number, and date of birth. Ensure accuracy for seamless processing.
4. Complete the Requesting Provider section with details like Provider ID, name, specialty, and contact information.
5. If applicable, provide Treating Provider details or check the box to have the Plan assign one.
6. Input Facility information if necessary. You can skip this section by checking the designated box.
7. Specify the Service Requested by entering the Planned Date of Service and relevant codes (ICD-9 and CPT).
8. Include a Pertinent Clinical Summary if needed and attach any supporting clinical records.

Start using our platform today to complete your Outpatient Authorization Request easily and for free!